Download West Virginia Physicians

CLINICIAN’S POCKET GUIDE FOR
Drugs, Alcohol and Tobacco
Screening, Brief Intervention,
Referral & Treatment
West Virginia
Physicians
Making a Difference
Tobacco, alcohol and drug misuse cause significant health
problems alone and complicate the management of other
medical problems. All patients should be screened for:
• Tobacco use
• Drug Use
• Alcohol use
• Prescription medication misuse
Any at-risk use should be addressed with a brief
intervention and a referral for further assessment
and treatment, if appropriate.
This pocket guide was produced with grant funds from the U.S. Substance Abuse
and Mental Health Services Administration (SAMHSA) administered through the WV
DHHR Bureau for Behavioral Health and Health Facilities.
SCREENING
ALWAYS REMEMBER TO:
•
•
•
•
•
•
•
•
Have a non-judgmental attitude!
Be aware of your own pre-conceptions and attitudes about substance abuse.
Acknowledge that you recognize that this information is difficult to talk about.
Ask open-ended questions initially and move to more directed questions as needed.
Assure the patient that you are asking because of concern for his/her health.
Pay attention to the manner in which the patient responds (eg. Indications of discomfort).
Always ask about current and past substance use.
Try to avoid using labels (like “alcoholic” or “addict”).
TIMING THE SUBSTANCE USE SCREENING:
• Ask about prescription medications and more socially acceptable substances (like
caffeine) first and then move on to tobacco, alcohol and illicit substances.
• Ask about family history of alcohol or drug abuse first and then ask about the patient’s own use.
• Ask about general health habits such as sleep, exercise and diet first and then get into
over-the-counter drugs, caffeine, tobacco, alcohol and illicit drugs.
• Ask about leisure activities/hobbies and ways of coping with stress.
• Ask about substance use whenever the patient brings it up for some other reason (such
as talking about their boss at work,etc.)
TOBACCO
#2): any use is a +
screen
#3) X #4):
= “pack-years”
1) “Have you ever smoked cigarettes or used other tobacco\
products?” If “YES”, ask:
2) “Have you smoked/used any in the past 30 days?” If “YES” ask:
3) “On average, how many cigarettes do you smoke (or times do you
use) per day?”
4) “How long have you been smoking (using) at that rate?”
• If daily use, can administer the Fagerström Tolerance Test.
AND
ALCOHOL
#2):>4(men) or
>3(women)
is a + screen
#3):
even once is a +
screen
#4) & #5):
“YES” is a +
screen
t
1) “How often did you have a drink containing alcohol, even beer
or wine, in the past year?” If any at all, administer AUDIT or
ask:
2) “How many drinks do you have on a typical day when you drink?”
3) “How often did you have 5 (for men)/4 (for women) or more drinks
on one occasion in the past year?” If #2) or #3) is +, ask:
4) “Has anyone ever thought you might have a problem with alcohol?”
5) “Have you or someone else ever been injured as a result of your
drinking?
6) If daily use, “Have you ever had seizures or other withdrawal
when
you stop?”
AND
PRESCRIPTION
MEDICATION
MISUSE
#1):
any “YES” is a +
screen
1) “Have you ever taken prescription medication that was not
prescribed for you or in a way that was not prescribed?”
If “YES”, ask:
2) “Tell me more about that…” or “Did you do this only for the
feeling/experience that it caused or to ‘self-medicate’?”
3) “Have you done this in the past 3 months?”
AND
DRUGS
#1) & #2):
any “YES” is a +
screen
#4):
any “YES” is a +
screen
1) “Have you ever used any drugs such as marijuana, heroin,
cocaine, PCP, LSD, methamphetamine, Ecstasy?”
If “YES”, administer the DAST-10 or ask:
2) “Which have you used in the past 3 months?”
For each substance, ask:
3) “How much are you using per day?” & “When did you last use?”
4) “Have you ever used any drugs by injection?” If “YES”,
recommend
HIV/Hepatitis B&C testing
SCREENING
FAGERSTRÖM
TOLERANCE TEST
• An 8-question tool designed to measure physical dependence to
nicotine
• Can help assess for need for medication to assist with cessation
• Can be self-administered or administered by healthcare professional
http://mayoresearch.mayo.edu/ndc_education/upload/ftnd.pdf
http://www.nova.edu/gsc/nicotine_risk.html
AUDIT
(Alcohol
Use
Disorders
Identification
Test)
• A 10-question screening tool
• Can be self-administered or administered by healthcare professional
• Takes about 5 minutes
• Recommended by WHO and NIAAA www.niaaa.nih.gov/guide
• Click “Guide” & select English or Spanish version
DAST-10
(Drug
Abuse
Screening
Test)
• A 10-question screening tool
• Adapted from the DAST
• Can be self-administered or administered by healthcare professional
• Recommended by NIDA
http://archives.drugabuse.gov/diagnosis-treatment/DAST10.html
CRAFFT
(FOR
ADOLESCENTS)
1. “Have you ever ridden in a CAR driven by someone (including
yourself) who was ‘high’ or had been using drugs or alcohol?
2. “Do you ever use drugs or alcohol to RELAX, feel better about
yourself or fit in?”
3. “Do you ever use alcohol or drugs while you are ALONE?”
4. “Do you ever FORGET things you did while using alcohol or
drugs?”
5. “Do you FAMILY or FRIENDS ever tell you that you should cut
down on your drinking or drug use?”
6. “Have you ever gotten in TROUBLE while you were using drugs
or alcohol?”
Any “YES” is a
+ screen
BRIEF INTERVENTION BASICS
STAGES OF CHANGE
Precontemplation
Contemplation
Preparation
Action
Maintenance
OARS
READS
Open-Ended Question
Affirmation
Reflective Listening
Summary Statements
Roll with Resistance
Express Empathy
Avoid Argumentation
Develop Discrepancy
Support Self-efficacy
(Techniques)
(Principles)
EFFECTIVE MOTIVATIONAL STYLES
Collaboration: Partnership that honors patient’s expertise and perspective
Evocation:
Explore patient’s perceptions of his/her preferences, goals and
values to spark motivation for change
Autonomy:
Affirm patient’s right and capacity for self direction
BRIEF INTERVENTION
STEP 1:
RAISE
SUBJECT
• “I’d like to take a few minutes to talk about your ______ use.”
STEP 2:
PROVIDE
FEEDBACK
• “Your answers to the screening questions show that you may be at risk
for problems related to your _______ use. I am concerned about this.”
• Provide medical information about the particular substance use concern.
¾ General information (such as “Low-Risk” drinking limits)
¾ Specific information (to patient’s situation/medical conditions, etc)
• For alcohol, reinforce “Low-Risk” drinking limits
• Make clear recommendations:
“I think it would be good for you to_________.”
STEP 3:
ASSESS
READINESS
TO CHANGE
• On a scale of 0-10, how ready are you to change any aspect of your
______ use?” (Show the Readiness Ruler)
¾ If >1, ask “Why did you choose that and not a 0?”
¾ If ≤, ask “What would make this a problem for you?”
or “Have you ever done anything you wish you hadn’t while using
_______?”
¾ If >5, ask “On a scale from 0-10, how confident are you that you
can change this behavior?”
STEP 4:
ENHANCE
MOTIVATION
• “What connection do you see between your ______ use and your
______ medical problems/social problems/ER visit, etc.)?”
¾ If the patient sees a connection, reflect what the patient has said.
¾ If the patient doesn’t see a connection, help explore the reasons for
ambivalence.
• “Can we explore the pros & cons of continued use vs. cutting down/
stopping?” (Can use a Decisional Balance Sheet)
• Help to create a discrepancy between what the patient is saying &
important priorities/goals that may be threatened by his/her substance
use.
STEP 5:
NEGOTIATE
AND ADVISE
(may need
to refer to
treatment at
this point; see
STEP 8)
• “What would be your goal as far as your ______ use?”
¾ Try to come up with a specific goal
• “What steps can you take to cut back on your use?”
¾ Try to come up with a specific plan
• “What things can you do to improve your confidence that you can
change?”
• Summarize: “This is what I heard you say:__________”
• Provide handouts and other educational materials.
STEP 6:
ARRANGE
FOLLOW UP
• “I would like to see you back in a month to see how you are doing with
this.” Or
• “I would like you to follow up with your primary car doctor about this.”
STEP 7:
FOLLOW UP
• “How did you do with your goal with using _______?”
¾ If some change, reinforce & support continued progress.
¾ If no change, acknowledge that change is difficult, affirm any
positive steps taken, address barriers to change, renegotiate the goal
with using and plan, engage significant others.
¾ Consider the use of a medication (naltrexone, acamprosate,
disulfiram, buproprion, varenicline, nicotine replacement,
buprenorphine)
¾ Consider referral to mutual help group (AA, NA).
STEP 8:
REFERRAL TO
TREATMENT
• “I think you might benefit from some professional treatment beyond what
we can provide for you here.”
• Provide information on specific programs, if possible. (Eligibility for
programs will depend on patient’s insurance.)
TREATMENT RESOURCES
OTHER USEFUL NUMBERS
METHADONE PROGRAMS IN WEST VIRGINIA
BECKLEY TREATMENT CENTER,
INC.
BEAVER, WV
(304) 254-9262
CHARLESTON TREATMENT
CENTER,INC.
CHARLESTON, WV
(304) 344-5924
CLARKSBURG TREATMENT
CENTER
CLARKSBURG, WV
(304) 622-7511
CRC HEALTH GROUP, INC
WHEELING TREATMENT CENTER
TRIADELPHIA, WV
(304) 547-9197
HUNTINGTON TREATMENT
HUNTINGTON, WV
(304) 525-5691
MARTINSBURG INSTITUTE
MARTINSBURG, WV
(304) 263-1101
PARKERSBURG TREATMENT
CENTER
PARKERSBURG, WV
(304) 420-2400
VALLEY ALLIANCE TREATMENT
SERVICES, INC.
MORGANTOWN, WV
(304) 284-0025
WILLIAMSON, WV
(304) 235-0026
WILLIAMSON TREATMENT
CENTER, INC.
WV Prescription Drug Abuse Quitline
1-866-WV-QUITT
http:/wvrxabuse.org
WV Quitline – Smoking Cessation
877-966-8784
http://www.bebetter.net/wvquitline_home.html
WV Suboxone Prescribers
http://www.buprenorphine-doctors.com/suboxone-doctors/West-Virginia-WV.cfm
SUICIDE HOTLINES
WV
http://www.suicide.org/hotlines/west-virginia-suicide-hotlines.html
National
800-784-2433 (800-SUICIDE)
Life line Chat
800-273-8255 (800-273-TALK)
http://www.suicide.org
WVSBIRT
https://sbirt.1stchsservices.org/
WV PROGRAMS FOR PREGNANT MOTHERS
Drug Free Moms and Babies Program
Shenandoah Valley Medical Systems, Inc.,
(304) 263-7023
[email protected]
Greenbrier Valley Medical Center
[email protected]
WVU Department of Obstetrics and Gynecology
[email protected]
Pregnancy Connections
Thomas Memorial Hospital
[email protected]
(304) 647-6017
(304) 293-4880
or (304) 594-1313
(304) 766-3983
TREATMENT RESOURCES
Comprehensive Opioid Addiction Treatment
WVUHealthcare/Chestnut Ridge Center Outpatient/Morgantown (304) 598-4214
http://wvuhealthcare.com/hospitals-and-facilities/chestnut-ridge-center
ACT Unit/ Fairmont, 28 day
(304) 363-2228
Bob Mays Recovery Center/Residential/Clarksburg
(304) 623-2178
Renaissance/Huntington, Residential
(304) 525-7851 x4503
Turning Points/Beckley, Residential treatment
(304) 252-6783
WV Consumer Advocacy and Outreach (CACO) Division (304) 356-4826
Adults with Mental Health Issues and Addictions
http://www.dhhr.wv.gov/bhhf/sections/programs/
ConsumerAffairsCommunityOutreach/Pages/default.aspx
Alcoholics Anonymous
http://www.usrecovery.info/AA/West-Virginia.htm
WV Al-Anon & Alateen
http://www.usrecovery.info/Al-Anon/West-Virginia.htm
WV Narcotics Anonymous
http://www.usrecovery.info/NA/West-Virginia.htm
WV Treatment Centers & Programs
1-800-676-2451
http://www.usrecovery.info/Treatment-Centers/West-Virginia.htm
WV Mental Health Organizations
http://www.usrecovery.info/Mental-Health-Organizations/West-Virginia.htm
WV Addiction Services
Addiction Services by Type of Drugs
1-800-304-2219
Long Term Drug & Alcohol Treatment Facilities
1-800-304-2219
http://www.addicted.org/west-virginia-long-term-drug-rehab.html
WV Drug Alcohol Treatment Center & Addiction Rehab Programs
1-800-315-2056
http://www.cswf.org/West-Virginia/
The Healing Place of Huntington-long term residential treatment for males
(304) 523-4673
http://www.thehealingplaceofhuntington.org
If you are concerned about a healthcare professional who may have a
problem with mental illness and/or substance disorder, you can call for
advice, assistance and guidance:
West Virginia Medical Professionals Health Program
Phone: (304) 933-1030 • www.wvmphp.org
ALL CONTACTS ARE KEPT STRICTLY CONFIDENTIAL!
patient tools
DRINK LIMITS FOR LOW
RISK DRINKING
Per
Week
Per
Day
14
4
Men
Women
7
3
Average
>65
7
3
DECISIONAL BALANCE SHEET
Change
Behavior
Pros
Continue
Behavior
Cons
Pros
Cons
READINESS RULER
0
1
2
3
4
Not Ready
5
6
7
8
Unsure
9
10
Ready
OPIOID EQUIVALENCY*
Opioid
PO
IV/SC/IM
Opioid
PO
IV/SC/IM
buprenorphine
butorphanol
codeine
fentanyl
hydrocodone
hyromorphone
levorphanol
n/a
n/a
130 mg
?
20 mg
7.5 mg
4 mg
0.3–0.4 mg
2 mg
75 mg
0.1 mg
n/a
1.5 mg
2 mg
meperidine
methadone
morphine
nalbuphine
oxycodone
oxymorphone
pentazocine
300 mg
5-15 mg
30 mg
n/a
20 mg
10 mg
50 mg
75 mg
2.5-10 mg
10 mg
10 mg
n/a
1 mg
30 mg
*Approximate equianalgesic doses as adapted form the 2003 American Pain
Society (www.ampainsoc.org) guidelines and the 1992 AHCPR guidelines.
Not available = “n/a.” See drug entries themselves for starting doses. Many
recommend initially using lower than equivalent doses when switching between
different opioids. IV doses should be titrated slowly with appropriate monitoring.
All PO dosing is with immediate-release preparations. Individualize all dosing,
especially in the elderly, children, and in those with chronic pain, opioid naive, or
hepatic/renal insufficiency.
OPIOID CONVERSION TABLE
http://www.globalrhp.com/narcoticonv.htm
patient tools
A “STANDARD DRINK”
(a standard drink contains approximately 12-14 grams or 0.5 - 0.6 oz of pure alcohol)
Beer
(3-5%)
Malt Liquor
(7-10%)
Table Wine
(12-13%)
(Budweiser,
Miller, Coors,
Michelob,
Heineken,
Corona)
(Steele
Reserve,
Colt 45,
King Cobra,
Camo 40,
Black Bull,
Hurricane,
Mickey’s
Private Stock)
(Chardonnay,
Merlot,
Pinot Grigio,
Reisling,
Sangria)
12 oz.
6-8 oz.
5 oz.
“Double Deuce” = 2 drinks
“Quart” = 2 1/2 drinks
“40” of beer = 3-4 drinks
“40” of malt liquor = 6-7 drinks
Fortified
Wine (FW),
Port,
Sherry
(17-20%)
(Mad Dog
20/20, Night
Train Express,
Richard’s Wild
Irish Rose,
Thunderbird)
3.5 oz.
Brandy
(37-40%)
(Cognac,
Martell,
Hennessy,
E&J,
Courvoisier,
Remy Martin)
1.5 oz.
“Pint” = 2 1/2 drinks
“Pint” of FW = 4 drinks
“Fifth” = 5 drinks
“Fifth” of FW = 7 1/2 drinks
Liquor/
Distilled
“Spirits”
(40%)
(Vodka, Gin,
Rum, Scotch,
Whiskey,
Bourbon,
Tequila)
1.5 oz.
“Half Pint” = 4 1/2 drinks
“Pint” = 8 1/2 drinks
“Fifth” = 17 drinks
“Handle” = 40 drinks
BLOOD ALCOHOL CONTENT (%)
Body Weight
Drinks
90 lb 100 lb 120 lb 140 lb 160 lb 180 lb 200 lb 220 lb 240 lb
1
M
–
.04
.03
.03
.02
.02
.02
.02
.02
F
.05
.05
.04
.03
.03
.03
.02
.02
.02
2
M
–
.08
.06
.05
.05
.04
.04
.03
.03
F
.10
.09
.08
.07
.06
.05
.05
.04
.04
M
–
.11
.09
.08
.07
.06
.06
.05
.05
F
.15
.14
.11
.10
.09
.08
.07
.06
.06
M
–
.15
.12
.11
.09
.08
.08
.07
.06
F
.20
.18
.15
.13
.11
.10
.09
.08
.08
3
4
5
6
M
–
.19
.16
.13
.12
.11
.09
.09
.08
F
.25
.23
.19
.16
.14
.13
.11
.10
.09
M
–
.23
.19
.16
.14
.13
.11
.10
.09
F
.30
.27
.23
.19
.17
.15
.14
.12
.11
Subtract .015 every hour after drinking
> Legal Driving Limit
assessing quantity
COCAINE:
• Often comes in $10 (a “dime”) “vials”, “pills”, “bags.”
Crack Used in “rocks.”
• Powder also bought in 1/4 ounce, 1/8 ounce (“eightball”).
HEROIN:
• $10=1 “pill” = 1 “cap” = a “dime” - 1 “bag”
(also $6 and $20 bags).
• Also used in “grams” in some areas.
• Can be “raw” (uncut; up to 90% pure) or “scramble” (cut: 5-10% pure)
BENZOS:
• Ask about “pills” and then specify “…benzos like Valium, Xanax, Klonopin?
• Xanax* – 0.25mg “white football”; 0.5mg “peach football”; 1mg “blue
football”; 2mg white “bar” (4 segments)
Xanax XR – 0.5mg “white pentagon”; 1mg “beige square”; 2mg “blue
circle”; 3mg “green triangle”
• Klonopin* (“pins”)(round) – 0.5mg “orange”; 1mg “blue”; 2mg “white”
• Valium* – (cut-out “V” in center) – 2mg “white”; 5mg “yellow”; 10mg
“blue”
*(the appearance of generic brands may vary but doses are the same)
MARIJUANA:
• Ounces; joints (small cigarette size); blunts (large joint often in
hollowed-out cigar or rolled in cigar paper); bowls (of pipe/”bong”)
OPIOIDS
(Rx):
• Oxycontin (“Oxys”) – 10, 20, 30, 40, 60, 80, 160mg
• Percocet (“Percs”) – 2.5, 5, 7.5, 10mg oxycodone
• Vicodin – 5, 10, 15mg hydrocodone
NICOTINE:
• Pack contains 20 cigarettes (5-10 cigars); Carton contains 10 packs
• Snuff, Snus, “Dip”, Chewing/Dipping tobacco comes in cans, tins,
pouches
• Often report smokeless tobacco use in number of
times/”dips”/”pinches” per day
ALCOHOL:
• Ask about beer & wine specifically; many people don’t consider them to
be alcohol
• Ask if beer is 12,16 (“a pint”), 22 (“a double-deuce”), 32 (“a quart), or 40
(a “40”) ounces.
• Ask if the bottle/pint/quart/fifth/etc. is wine, beer, or liquor.
• Ask if it is consumed alone or shared with friends.
“Miniature” = 1.6oz Pint = 16oz
Quart = 32oz
“Fifth” = 25oz
Liter = 33.8oz “Handle” = 1.75 liters
Gallon = 128oz
Case = 24/12oz beers
Table Wine Bottle (750mL) = 25oz
Mixed drinks often contain >1.5oz of liquor
urine toxicology basics
• Drug screens are typically done with immunoassay; use cutoffs for various drugs
• Confirmation generally performed with GC/MS (more specific & expensive) or 2nd assay
• “Opiate” screens usually test for morphine. Will often NOT detect synthetic opioids
(Demerol, Methadone, Dilaudid, Fentanyl, Buprenorphine).
• “Amphetamine” screen may be false + for many cold preparations
(eg. pseudoephedrine)
• “Benzodiazepine” screens vary; may miss some common benzos like alprazolam
• Remember that opiates and benzodiazepines are often given for medical reasons
before urine is obtained
If you are unsure of meaning of a test result, “WEED it”:
1. Write out patients medicines
2. Examine the patient carefully
3. Equate test result with physical examination
4. Duplicate the test
alcohol & sedative hypnotics
Although >95%of alcohol withdrawal cases are uncomplicated
and self limited, withdrawal can be fatal!
Remember:
• Management of benzodiazepine & barbiturate withdrawal is the same as that for alcohol
• Chronic alcohol use can affect the liver; lowering dose of some medications may be
necessary
• Concomitant benzodiazepine abuse may delay, intensify & prolong withdrawal
DELIRIUM TREMENS (DTS)
• Typically seen within 72 hours
after last use; can be within
hours or up to 1 week
• Always evaluate for other causes
of delirium (head trauma, metabolic, etc.)
Increased risk of DTs:
•history of DTs •chronic alcohol use
•head trauma •older age
•concomitant medical problems
ALCOHOL WITHDRAWAL
SEIZURES
• Alcohol withdrawal seizures are
independent of DTs
• Typically seen 12-48 hours after
last use; can be as much as 1
week later
• Always evaluate for other causes
of seizures (head trauma, hypoglycemia), etc.
Increased risk of Withdrawal Seizures:
•history of withdrawal seizures
•head trauma
•history of other seizure disorder
•concomitant benzodiazepine abuse
WERNICKE’S
ENCEPHALOPATHY
• Prevention with thiamine is
crucial
Signs & Symptoms of Wernicke’s
Encephalopathy:
•nystagmus •confusion
•lateral gaze paralysis •diplopia •ataxia
•short-term memory deficits
Signs & Symptoms of DTs:
•hypertension •anxiety/agitation •tachycardia
•hyperactive reflexes •tremulousness
•hallucinations •diaphoresis •disorientation
•insomnia
TREATMENT OF WITHDRAWAL
• Remember that Delirium Tremens is much easier to prevent than to treat once
present
• A shorter-acting benzodiazepine does not speed-up the detox
Symptom-triggered:
• Monitor signs and symptoms of withdrawal regularly (q10-60 mins) and initiate benzodiazepine at earliest sign of withdrawal:
Valium (diazepam) 10mg IV then 5-10mg PO/IV q 15-60 mins until sedated
• If available, use protocol linked to standardized assessment (AWS; CIWA)
Standing order of benzodiazepine:
• May be more practical due to staffing or if patient at very high risk for DTs or withdrawal
seizures
•Valium (diazepam) 10-20mg PO or IV q 6 hours
•Librium (chlordiazepoxide) 50-100mg po q 6 hours
•Ativan (lorazepam) 2-4mg PO or IV or IM q 1-6 hours
Need to individualize dose:
• Some patients will need much higher doses
• Give enough until sedated or cessation of signs and symptoms of withdrawal
• Taper by 20-25% of dose/day (after pt. stable for 24 hrs); slower if patient unstable
heroin & other opioids
REMEMBER: You can die from overdose but not withdrawal
(except neonates & very ill)
OPIOID
INTOXICATION/
OVERDOSE
Signs & Symptoms:
•respiratory depression
•apathy
•slurred speech
•impaired judgment
•constricted pupils
•drowsiness
•pruritus
•impaired attention
•coma
TREATMENT OF OVERDOSE
1) Establish adequate oxygenation
2) Administer Naloxone (Narcan) (response typically seen in 1-2 minutes)
• Start with 0.1-0.4mg IV (2mg IV if comatose or apneic)
• May need to repeat dose if overdose on methadone or Oxycontin
• May need higher doses (10mg) if overdose on high potency opioid (Fentanyl)
OPIOID
WITHDRAWAL
Signs & Symptoms:
•dilated pupils •lacrimation irritability/dysphoria •anxiety
•piloerection •restlessness •diaphoresis •diarrhea •craving
•abdominal cramping •rhinorrhea •nausea/vomiting aches
(especially back/legs) •tachycardia •hypertension
TREATMENT OF WITHDRAWAL (in hospitalized patients)
• If patient says he/she is on a methadone program, call the program, document
the dose and staff person you talked to and resume that dose unless patient is overly
sedated.
If unable to contact program, only give 20-40mg PO (10-20mg IV if unable to take PO)
until confirmed
• If patient says he/she is on buprenorphine (tablets or film) maintenance, and is
not in significant pain, continue maintenance dose. If in significant pain, may need to
discontinue buprenorphine & start opioid. (May require higher dose).
• If patient is in significant pain, place on a standing dose of an opioid.
• Remember, someone who is dependent on opioids will likely need a higher dose!
• If patient is not in significant pain, not likely to go to surgery and not pregnant,
can start on buprenorphine/naloxone (Suboxone): Requires DEA waiver.
• 4-8mg sublingually initially w/ 2-4mg every 8-12 hours prn for additional sxs.
• If the patient is unable to take sublingual (eg. delirious, agitated), can use Buprenex
0.3-1.2mg IM or IV (not “push”) q 6-12 hours.
• Can treat various signs/symptoms symptomatically:
•muscle aches - ibuprofen •spasms - methocarbamol
•nausea - Phenergan, Bentyl •irritability - benzodiazepines
•insomnia - trazodone
•diarrhea - Imodium, Kaopectate
IMPORTANT FACTS ABOUT BUPRENORPHINE:
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Use higher doses for higher heroin use or current pain issues.
Begin to taper 3-4 days prior to discharge.
Don’t give within 6-12 hrs. after an opioid; may precipitate withdrawal!
May need to wait >24 hours after long-acting (methadone, Oxycontin, MS Contin).
Opioids will be relatively ineffective for 8-24 hrs after buprenorphine.
Use NSAIDs, ketorolac, regional anesthesia for additional pain control.
commonly abused substances
other than alcohol, nicotine & caffeine
Pot; Weed; Reefer; Dope; Grass; Boom; Herb; Hash; Blunt;
Sinsemilla; Sinse
Dope; Junk; Smack; Black Tar; Herrron; H; OxyContin-Oxys;
Percocet-Percs; Meth
Hallucinogen
PO/I
I
II (Marinol)
Opioid I/II/III
PO (tablet)
smoked (rare)
PO
IV (rarely)
mucosally
PO
smoked;
PO (rarely)
IV; IN; smoked;
PO
IV; IN; smoked
IN; IV; smoked
nystagmus (D, CD); ataxia; analgesia; rigidity;
Djudgment/resp.; confusion; coma
Cenergy/confidence/anxiety/empathy CBP/HR/temp;
illusions; MI; bruxism
relaxation; sedation; disinhibition; slurring;
Djudgment/coordination/resp; amnesia; coma
hallucinations; illusions; delusions; restless;
disorientation; Djudgment/coordination
red eyes; Cappetite/HR; euphoria; lethargy;
Dconcentration/memory/judgment/coord.
apathy; lethargy; constricted pupils; pruritis;
constipation; Drespiration; coma; death
Cenergy/confidence/anxiety;psychosis CBP/HR/
temp; stroke; MI;
Dappetite; rhabdo
Cenergy/confidence/anxiety;psychosis CBP/HR/
temp; stroke; MI;
Dappetite; rhabdo
minimal-irritability
minimal-irritability; headache
nonspecific
fatigue; lethargy; hypersomnia;
depression; suicidal ideation
disorientation; CHR/BP/temp;
tremors; hallucinations; agitation;
seizures
none
irritability; anxiety; insomnia; nausea
diaphoresis; rhinorrhea, dilated pupils;
diarrhea; nausea/vomiting; irritability
fatigue; lethargy; hypersomnia;
depression; suicidal ideation; craving
fatigue; lethargy; hypersomnia;
depression; suicidal ideation; craving
WITHDRAWAL EFFECTS
–
–
–
2-4
14 (chronic)
1-3
5 (chronic)
1-14
30 (long act)
<1
1-7 (light)
35 (heavy)
2-3
2-3
3-4
DETECTION
PERIOD
(DAYS)
Methamphetamine
INTOXICATION EFFECTS
Heroin/Prescription
Opioids
Acid; Window Pane; Microdot; Blotter; Cactus; Mescal; Magic
Mushrooms; Shrooms
SedativeHypnotic
IV
IN; IM
PO (liquid)
syncope; giddiness; Dsenses; amnesia; DBP, enhanced
orgasm; hypoxia; nausea; coma
irritability; headache; insomnia;
depression
Paint/Glue/Toluene
Hydrocarbons
HOW TAKEN
Marijuana
Pills; Tranks; Klonopin-Pins; Xanax-Bars; Zanny Bars;
Rohypnol- Roofies; Roofenol
PsychedelicStimulant/I
Inhaled (IN)
mild euphoria; Dinhibitions/pain; sedation; frost burn;
neuropathy
insomnia; depression; irritability
hours;days
20
>90 (injected)
STREET NAMES
LSD
Mescaline/Psilocybin
Ecstasy; X; Clarity; E; XTC; Rave; Rolls; Adam; Lover’s Speed;
M&M; M; Essence; Molly
Dissociativeanesthetic/III
Inhaled (oral)
bad breath; slurred speech; nausea/vomit Djudgement/
coordination/resp; arrhythmias
unknown
DRUG NAME
Benzodiazepines/
Barbiturates
Special K; K; Jet; Ket; Kit Kat; Super K; Vitamin K; Super Acid;
Cat Valiums; Purple
Inhalant
Vasodilator
huffed/inhaled
(IN + oral)
agitation; aggressiveness (“roid rage”) CBP/HR/temp/
sweat; insomnia; paranoia
CLASS/
DEA
SCHEDULE
MDMA
Poppers; Snappers; Amys; Rush; Bullet; Sweat; Climax; Locker
Room; Bolt; OZ
Inhalant
General
Anesthetic
IM
PO
Stimulant
II
Ketamine Hcl (Ketalar)
Laughing Gas; Whippets; balloons
Solvent;
Adhesive;
Propellant
IN; IV; PO
unknown; likely similar to Marijuana
Coke; Blow; Bump; Toot; Snow; Flake; C; Crack; Ready; Rock;
Ready Rock
Nitrates (amyl/butyl/
cyclohexyl/Nitrates)
Glue; Hardware; Gas
Anabolic Steroid
III
Cenergy; CHP/BP;agitation; euphoria; insomnia;
hallucinations; delusions; panic
Cocaine
Nitrous Oxide
Roids; Juice; Arnolds; Gym Candy; Pumpers; Equipose;
Stanazolol; Winstrol; Testosterone
sedation; disassociation; euphoria; paranoia; psychosis
Stimulant
II
Anabolic Steroids
Bath Salts; Plant food; Pond Scrum Remover
Smoked
Crystal Meth; Speed; Crank; Meth; Ice; Chalk; Fire; Getgo;
Methlies Quik; Glass
Mephedrone (MDPV)
I
Psychedelic
Stimulant/I
hours;days
K2; Spice; Bliss; Scooby Snax
Synthetic Cannabonoid